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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5259_Библиотеки_им_академика_М_И_Перельмана.pdf
deformity and the non-physiologic orientation of
the fusion mass
B. Risk of further slippage is related to the type of
slip and the amount of initial sagittal plane
deformity.
C. Disc degeneration may increase the risk of slip
progression
D. Decompression alone by removing all the poste-
rior elemen ts (Gill’s procedure) can be performed
alone in grade II and III spondylolisthesis, because
it provides fast symptoms improvement and the
same rate of slip progression of posterior instru-
mented surgery.
E. B + D
Preferred Response: D: Surgical technique plays a pivotal
role in determining the risk of slip progression after the
treatment of spondylolisthesis. In situ fusion with removal of
posterior elements for decompression is associated with a
higher rate of slip progression and kyphosis. A fortiori,
complete removal of the posterior elements at the slipped,
lytic level, known as the Gill procedure, increases the risk of
slippage. Even if this procedure is associated with good short
terms clinical outcomes, its biomechanical long terms results
are much worse than the other procedures [52].
(90) After a L2 vertebroplasty you detect an intradiscal
cement leakage. What will you expect regarding
patient’s clinical outcomes?
A. Higher risk of adjacent vertebra collapse
B. Higher risk of delayed neurological deficits
C. Delayed pain relief
D. A + B
E. A + B + C
Preferred Response: C: Intervertebral cement leakage has
been classified in three types: Type I intervertebral
extra-discal leakage, Type II intradiscal leakage and Type III
combined. It has been proven not to be related with an
increased risk for adjacent vertebral fractures, and impaired
outcomes in terms of pain relief or improvement of physical
function. Intradiscal leakage is the most common type of
cement leakage, and it is related to delayed pain relief [53].
(91) Which of the following sentences is false regarding
post-operative kyphosis after cervical laminectomy?
A. The correlation between the development of
post-operative kyphosis and neurologic outcomes
has not been demonstrated.
B. Long term deterioration results from the draping
and compression of the spinal cord over the ven-
tral kyphotic deformity.
C. The incidence of late deterioration following cer-
vical laminectomy varie s from 10 to 39%.
D. Post-operative kyphosis is caused by the loss of
the posterior tension band and the loss of the
posterior cervical musculature.
E. The incidence of post-laminectomy kyphosis is
higher in adults then in children
Preferred Response: E: The incidence of post-laminectomy
kyphosis ranges from 6 to 47% in adults and up to 100% in
children. In children, there are two types of postoperative
cervical laminectomy kyphosis: wedging of the vertebral
bodies and subluxation with excessive motion between
vertebrae. Several studies found a rate of post-laminectomy
kyphosis near to 100% in children; therefore, fusion is
required after posterior cervical decompression [54].
(92) What is the correct definition of pseudomeningocele?
A. Pseudomeningocele is a postoperative extra-
vasated collection of extradural CSF that com-
municates with the subarachnoid space through a
breach in the dura mater and arachnoid.
B. Pseudomeningocele is a cystic dilatation of the
meninges containing cerebrospinal fluid without
any neural tissue.
C. Pseudomeningocele is a birth defect in which the
spinal canal does not close before birth.
D. Pseudomeningocele is an extradural CSF com-
munication with the subcutaneous space or a direct
communication with the outside through the skin.
Preferred response: A: Pseudomeningocele is defined as a
postoperative extravasated collection of extradural CSF that
communicates with the subarachnoid space through a breach
in the dura mater and arachnoid. CSF fistula relies on the
same mechanism and occurs when there is a direct commu-
nication of the CSF with another cavity or with the outside.
(93) A twenty-two years old patient with rheumatoid arthritis
has been treated with a C0-C4 occipito-cervical fixation
for basilar invagination. After implant failure and revi-
sion surgery with the removal of the articular mass
screws and placement of C3-C4 laminar clamps, she
developed CSF leak and fever. Pseudomonas aeruginosa
was isolated from the wound. She was treated with
broad spectrum antibiotics, and she underwent surgery
for debridement, CSF leak Repair with fibrin glue and
meticulous reconstruction of the superficial layers.
Nevertheless, after 10 days the wound presented a cra-
nial dehiscence with hardware exposure (Fig. 10.8).
What could be the proper management?
A. Hardware removal and VAC therapy
220 A. Bocchetti et al.
B. Stand-alone rotation scalp-flap
C. Pericranial and scalp rotation flap
D. Hardware removal, stand-alone rotation flap and
transoral surgery for the basilar invagination
E. New debridement and local instillation of
rifampicin
Preferred Response: C: Pericranial and scalp rotation flap
offers a double-layer barrier for preventing recurrent CSF
leakage and separating the occipital plate from the skin.
Furthermore, it reduces the wound pressure, and improves
vascularization to the surrounding tissues [21].
(94) Which of the following is the best strategy for avoiding
cage subsidence after ACDF?
A. Using the smallest cage that suites the intradiscal
space
B. Sparing the endplates avoiding the use of the drill
C. Extensive using of the drill for opening the Lus-
chka’s joints
D. Insert the cage after removal of cervical distractor
E. None of the above
B: Cage subsidence may be cause by several factors, such
as shape of endplates and, cage materials and shape. Nev-
ertheless, sparing the endplates Remains the mainstay of a
proper strategy aimed at avoiding this occurrence [55].
(95) A 58 years-old patient was treated with a two stages
approach: L3-L4 XLIF (left side) and L3-L4 posterior
fixation with percutaneous pedicle screws insertion. He
had a long history of low back pain and neurogenic
claudication. MRI showed a central and left paracentral
disc herniation leading to sever critical canal stenosis
with foraminal narrowing due to disc height loss At
L3-L4. Neurological examination Showed only bilat-
eral hypoesthesia (left > right) In the L3 distribution.
After surgery he was placed on enoxaparin 6000 units
subcutaneously per day and his coagulation profile
pre-operatively was normal. Six days after surgery he
developed groin pain and numbness and weakness of
quadriceps femoris with loss of knee extension on the
left side. Hip flexion was Pain limited. Furthermore, he
was found to have lateral flank bruises and a drop in
hemoglobin from 11 to 7.2 g/dL. What do you suspect?
A. Retroperitoneal hemorrhage due to left internal
iliac artery injury
B. Retroperitoneal hemorrhage due to left common
iliac artery injury
C. Femoral nerve palsy due to XLIF approach and
normal hemoglobin drop after two steps approach
D. Retroperitoneal hemorrhage due to left psoas
hematoma
E. L3 root injury due to misposition of left L3 screw
Preferred Response: D: Ileopsoas hematoma is a rare
complication (reported from 0,18% to 1,7% of cases) of
lateral lumbar interbody fusion. It can be caused by seg-
mental artery injury, whose bleeding can be undetected
during surgery. Moreover, coagulation disorders or use of
anticoagulants may increase the risk of its occurrence. This
complication may lead to lumbar plexus palsy, hemoglobin
dropping and can be life-threatening if the bleeding leads to
hypovolemic shock. Therefore, even if rare, its occurrence
should be taken into account by physicians [56].
(96) What is the proper management of psoas hematoma?
A. Patients should always undergo emergency evac-
uation surgery
B. Intervention is always recommended. Surgeons
may choose between surgery or CT guided drai-
nage, according to the size of the hematoma.
C. Iliopsoas hematomas can be managed conserva-
tively if there is no clinical and hemodynamic
deterioration
Fig. 10.8 Postoperative photograph of the occipito cervical region
demonstrating dehiscence with exposure of the superior aspect of the
occipital plate
10 Complications of Surgery of the Spine 221
D. Conservative treatment is always recommended
since neurological deficit will be transient.
E. None of the above
Preferred Response: C: Treatment strategy of iliopsoas
hematoma is controversial. The state of the art suggests
managing conservatively patients that do not show signs of
clinical or neurological deterioration. Conservative man-
agement consists of stopping anticoagulants, fluid and blood
(if needed) administration and Se rial evaluation of hemo-
globin and coagulation profile. Surgical intervention is
warranted in case of hemodynamic instability and progres-
sive neurological deficit [56].
(97) Which of the following is a proper method to reduce
the risk of sacral instrumentation bulkiness in high
grade spondylolisthesis?
A. In high grade spondylolisthesis the sacrum should
not be included in the construct
B. Patient in prone decubitus for three days after
surgery
C. Distal rods as short as possible
D. Using only S2 alar screws
E. None of the above
Preferred Response: C: In cases of high-grade spondy-
lolisthesis, the posterior cortex of the sacrum is close to the
skin. Therefore, the rod caudal extremity lays just below the
skin and can Be protruding after edema resorption. Thus, it
is be better to leave the distal rods, below the sacral screws,
as short as possible to reduce the risk of such occurrence.
(98) Which of the following sentences is true about pedicle
subtraction osteotomy (PS O)?
A. In adult rigid scoliosis, PSO alongside posterior
lumbar and sacropelvic fusion provides better
sagittal and coronal correction than two stages
(anterior/lateral + posterior) approaches and simi-
lar complication rates.
B. In adult rigid scoliosis, PSO alongside posterior
lumbar and sacropelvic fusion provides Similar
sagittal and coronal correction of two stages
(anterior/lateral + posterior) approaches and lower
complication rates.
C. In adult rigid scoliosis, PSO alongside posterior
lumbar and sacropelvic fusion provides Similar
sagittal and coronal correction of two stages
(anterior/lateral + posterior) approaches and
higher complication rates.
D. In adult rigid scoliosis, PSO alongside posterior
lumbar and sacropelvic fusion provides better
sagittal and coronal correction of two stages
(anterior/lateral + posterior) approaches and
higher complication rates.
E. In adult rigid scoliosis, PSO alongside posterior
lumbar and sacropelvic fusion provides better
sagittal and coronal correction of two stages
(anterior/lateral + posterior) approaches and lower
complication rates.
Preferred Response: A: The current trend in adult rigid
scoliosis foresees the preferred employment of posterior
only approaches instead of two stages surgery. In this sce-
nario where these strategies provide same clinical results, the
pedicle subtraction osteotomy along with posterior fusion
increases sagittal and coronal plain correction having an
overall complication rate similar to the two stages approa-
ches [57].
(99) Which of the following sentences is false regarding
complications of dynamic stabilization of the lumbar
spine?
A. The complications with the dynamic systems are
similar to those seen with standard fusion systems
B. Loss of bone screw interface is a late complication
(> 6 months)
C. In case of failure, revision surgery should be aimed
at perfor ming a bony arthrodesis
D. A + B
E. A + B + C
Preferred Response: B: Dynamic stabilization for lumbar
spine is an attempt to push spine surgery beyond its previous
limits. Its goals are to maintain control of segmental motion,
neutralizing excessive forces, improving spinal alignment,
preserving motion, and preventing adjacent-level disease.
This technique carries the same complications of standard
fixation. Therefore, complications as dural tears are the most
common occurrence and symptomatic loss of bone–screw
interface is an early (less than3 months) postoperative
complication [58].
(100) What is the “fusion disease” referred to transverse
process fusion?
A. A unique type of pseudoarthrosis that occurs
after transverse proces s fusion
B. Unilateral fusion failure that leads to coronal
imbalance
C. Retroperitoneal hematoma due to injury of the
segmental vessels
D. Postoperative back pain
E. Unilateral sympathetic chain injury
222 A. Bocchetti et al.
Preferred Response: D: Fusion syndrome in the context of
transverse process fusion is characterized by postoperative
pain resulting from excessive retraction or devascularization
of the paraspinal muscles during lengthy fusion operations.
(101) How is it possible to reduce the risk of “fusion dis-
ease” after transverse process fusion?
A. Correct choice of the patients (e.g., obese, smo-
ker patients, as well as patients with high grade
scoliosis should be considered not suitable for
this surgery)
B. Familiarity with segmental vessels anatomy and
their early identification and coagulation
C. Using the neuromonitoring for early identifica-
tion of the lumbar plexus
D. Avoiding monopolar electrocautery
E. Periodic release of self-retaining retractors
Preferred Response: E: Periodic release of self-retaining
retractors should be carried out to avoid paraspinal muscles
compression leading to injury and ischemia that are the
cause of “fusion disease”.
(102) Profuse venous bleeding during AxialLIF procedure…
A. …can occur frequently while creating the sacral
channel with the drill and durin g the diskectomy
B. … can be controlled effectively using Flo-Seal or
other hemostatic agents at the entry point
C. … tamponades with placement of the device.
D. …it is never caused by vascular injury due to the
trajectory of the implant
E. A + B + C
Preferred Response: E: During AxialLIF profuse bleeding
is rare. Of course, a proper evaluation of vessels anatomy
should be performed before surgery to rule out vascular
abnormalities. Nevertheless, venous bleeding can frequently
occur when drilling the sacrum and when performing the
discectomy. The use of floseal of other hemostatic agents, as
well as the placement of the implant, are good strategies to
stop the bleeding. Leaving a small portion of the device
protruding from the sacrum adds further strength to the
construct and seals sacral bleeding. Even if rare, vascular
injuries are reported during AxialLIF and thus, if the
bleeding cannot be stopped or in cases of development of
cardiovascular instability, an e mergent vascular consultation
is recom mended [59].
(103) What is the range of vertebral artery injury after
posterior cervical spine non instrumented
decompression?
A. < 0.5%
B. 0.5–1%
C. 1–5%
D. 5–10%
E. 10–15%
Preferred Response: A: Vertebral artery injury is a very
rare complication of posterior spinal surgery, occurring
reportedly around 0.07%. Nevertheless, it is more common
with inexperienced surgeons. It carries a 10% risk of neu-
rologic sequelae or death [60].
(104) Which of the following sentences is true regarding
Smith Petersen Osteotomy (SPO)?
A. Vascular complications are due to lengthening of
the anterior column
B. Neurologic complications rate is higher than with
pedicle subtraction osteotomy
C. Foraminotomy should be avoided at level of SPO
D. A + B
E. A + B + C
Preferred Response: D: Most of the complications related
to SPO are due to lengthening of the anterior column.
A fortiori, the risk of vascular complication is higher in cases
of either elderly patients or patients with ankylosing
spondylitis because of calcified vessels. Neurologic com-
plications (30% after SPO and 11–16% after PSO) are
mostly featured by radiculopathy due to foraminal narrow-
ing. Therefore, wide foraminotomy is warranted at the level
of a SPO [61].
(105) Which of the following conditions increases the risk
of neurological injury during intubation?
A. Rheumatoid arthritis
B. Cervical spinal stenosis
C. Ankylosing spondylitis
D. Down syndrome
E. All of the above
Preferred Response: E: Several conditions may increase the
risk of neurological injury with intubation (e.g., cervical
spondylosis with spinal canal stenosis, congenitally narrow
spinal canal, ankylosing spondylitis, rheumatoid arthritis).
Down syndrome increases both the risk of neurological
deficit due to the high rate of atlantoaxial instability (20%
approximately) and issues related to the intubation itself
(microcephaly, macroglossia, subglottic stenosis, airways
obstruction, respiratory tract infections).
(106) Which of the following is not a major risk for pos-
terior cage migration in posterior lumbar interbody
fusion?
10 Complications of Surgery of the Spine 223
A. Bullet shaped cages
B. Preoperative spine mobility
C. A + B
D. Undersized cages
E. Posteriorly located cages
Preferred Response: C: Posteriorly located cages and
undersized cages significantly increase the risk of posterior
cage migration. Other factors, such as cage shape and high
preoperative spine mobility, do not increase the odds of such
occurrence. Thus, cage height should be equal or bigger to
preoperative disc height and the cage center should not be
placed posteriorly to the disc center [62].
(107) A 63 years-old woman Underwent a C5-C6 ACDF
and C5-C7 anterior plating at another hospital. Prior
to surgery she complained of neck pain (VAS 6/10)
and left C5 radiculopathy. You see her one month
after surgery, complaining of neck pain (8/10).
Radiologic investigations showed implant failure.
What could be the reason for this occurrence?
A. She has pre-operative cervical kyphosis. In these
cases, a 360° approach is indicated.
B. The anterior plating involved a non-fused level.
C. The anterior plating should have involved also
C4-C5
D. All of the above
E. None of the above
Preferred Response: B: Anterior plating of cervical spine
should only involve fused levels. In fact, in this case the
preserved range of motion at C6-C7 led to implant failure
[63].
(108) Which cervical level has the highest and lowest risk of
developing adjacent segment disease?
A. Highest: C6-C7; Lowest: C2-C3
B. Highest: C2-C3; Lowest: C5-C6
C. Highest: C5-C6; Lowest: C2-C3
D. Highest: C4-C5; Lowest: C6-C7
E. Highest: C3-C4; Lowest: C5-C6
Preferred Response: C: Middle and lower subaxial spine
are more prone to develop adjacent segment disease. The
most interested level is C5-C6, due to the higher predispo-
sition to develop spondylosis and adjacent segment disease.
Contrariwise, the level that proved to be less affected by this
condition is C2-C3 [64].
(109) A 56 years-old patient underwent a posterior C3-C7
decompression and fusion. The surgery was completed
with intraoperative CT-scan. The last control showed
correct placement of the Hardware even though the
articular mass screws only had uni-cortical bony pur-
chase. After surgery the patient woke up anisocoric
(dx > sx). What can be the cause of such occurrence?
A. Bernard-Horner syndrome due to lesion of
sympathetic chain
B. Parfour du petit syndrome due to irritation of
sympathetic chain
C. Epidural hematoma
D. Iris sphincter muscle tears
E. None of the above
Preferred Response: D: Iris sphincter muscle tears and
transient or permanent dilation of the affected pupil may be
caused by wrong position and long surgical duration. Fixed
dilated pupil is a condition featured by an abnormality of the
iris, that causes cosmetic issues, and requires further con-
servative or surgical intervention.
(110) Which of the following sentences is false regarding
lumbar adjacent segment disease (ASD)?
A. Increasing age is an independent risk factor for
ASD
B. Including the sacrum into the construct increases
the risk of ASD
C. Adjacent laminectomy during the initial surgery
is associated with higher risk of ASD
D. The number of fused segments is related to the
risk of ASD
E. Interbody fusion adds rigidity to the construct
increasing the risk of ASD
Preferred Response: B: ASD is a multifactorial event
whose primary cause is the rigidity of the segment that
redistributes the axial and shear load. Therefore, all the
instrumented segments, particularly when an interbody
fusion is added to the construct, are at higher risk for ASD.
Moreover “floating fusions”, namely fusions not including
the sacrum, are more prone to develop adjacent segment
disease than instrumented fusions that included the sacrum.
Other risk factors for ASD are increasing age, adjacent
laminectomy, and number of fused segments [65].
(111) Which of the following sentences is true regarding a
proper cantilever beam fixation?
A. The cantilever beam effectiveness can be
increased by using larger diameter screws, longer
screws, multiple screws per level, augmentation
of the cancellous or cortical bone, and cross-links
for longer constructs
B. Higher moment applied to the construct leads to
higher risk of failure
224 A. Bocchetti et al.
C. Segmental fixation, attention to sagittal balance
and proper posture postoperatively can decrease
the appli ed moment to the implant.
D. A + B
E. A + B + C
Preferred Response: E: Understanding the applied loads on a
construct and the physical basis behind its function is one of
the mainstays of spine surgery. The implants work as a can-
tilever beam subjected to a shear force, an applied load, and a
moment. The higher is the moment applied, the higher is the
risk of implant failure. Therefore, several strategies exist in
order to reduce the moment, namely segmental fixation instead
of nonsegmental fixation, attention to sagittal balance and
proper posture postoperatively. Likewise, using larger diame-
ter screws, longer screws, multiple screws per level, aug-
mentation of the cancellous or cortical bone, and cross-links
for longer constructs can improve the resistive moment.
(112) Which of the following is a correct strategy for
avoiding pneumothorax after retro pleural approaches
to the ventral thoracolumbar spine?
A. In cases of pleural tear, tube thoracostomy should
not be placed if the lung remains adheren t to the
parietal pleura
B. If pleural tears occur, it should not be repai red
with sutures if the lung remains adherent to the
parietal pleura
C. In cases of dural tear, if an air leak is present
(indicated by separation between the lung and
parietal pleura) a tube thoracostomy is placed and
left in place for 7 days.
D. A + B
E. None of the above
Preferred Response: A: After the procedure the pleura
should be carefully inspected. If pleural tears are encoun-
tered, they should be always repaired with sutures. Even in
cases of tears, if the lung remains adherent to the parietal
pleura there is no need for tube thoracostomy. If separation
between the lung and parietal pleura is detected a tube
thoracostomy is placed and removed the next day. The latter
condition indicates either an air leak (i.e., lung parenchymal
entry) or a nonairtight pleural tear closure [66].
(113) Which of the following is a proper closure technique
to avoid CSF leak due to dural tear after endoscopic
endonasal approach to the craniovertebral junction?
A. Patch of synthetic dura and hemostatic sponge
B. PMMA
C. Autologous material s (Fat, flap, fascia lata), fib-
rin glue, and fast mobilization of the patient
D. Lumbar drainage
E. C + D
Preferred Response: C: Autologous materials, hemostats,
and sealants (oxidizes cellulose, fibrin glue, Tachosil) are the
mainstays for an effective reconstruction in cases of CSF
leak during endoscopic endonasal surgery. Specifically
vascularized flaps are reliable methods to bolster the
reconstruction. Overall, this strategy proved to reduce CSF
fistula rate below 2% in a comprehensive series. Neverthe-
less, approaches to the craniovertebral junction carry a high
risk of fistula in cases of CSF leak. Patients are kept on bed
rest for less than 24 h, with the head of the bed elevated to
30 degrees, after which they are actively mobili zed [67].
(114) Which of the following sentences is false about sur-
gical site infection?
A. Hair removal is a fundamental pre-operative step
for reducing the risk of surgical site infection.
B. Maintenance of slight hypothermia during a
surgical procedure proved to reduce the risk of
surgical site infection.
C. Surgical drains increase the risk of surgical site
infection by removing the blood that is consid-
ered a natural antiseptic agent
D. All of the above
E. None of the above
Preferred Response: D: All the answers all false. There is
no evidence that hair removal lowers the risk of surgical site
infection. Moreover, several large and well-designed trials
proved that hair removal done with razors is clearly asso-
ciated with higher rates of surgical site infections as com-
pared with other tools as electric clippers or depilatory
creams. Hypothermia during the procedure can impair
immune function, by reducing antibody production,
decreasing chemotaxis, and phagocytosis. Therefore, main-
tenance of normothermia during a surgical procedure is
perhaps one of the most important tools in preventing sur-
gical site infection. Lastly, there is no proof that drains
increase the risk of surgical site infection. The two opposed
theories are: i) that drains remove blood (considered as an
excellent culture medium), remove bacteria, and prevent
hematoma formation; ii) drains can be themselves conduit
for bacteria [34].
(115) C2 neuralgia can frequently occur…
A. After occipito-cervical fixation (C0-C4)
B. C1-C2 Harms fixation when inserting the screw
in C2
C. C1-C2 Harms fixation when inserting the C1
lateral mass Screw
10 Complications of Surgery of the Spine 225
D. In all procedures when C2 lateral mass is
exposed
E. None of the above
Preferred Response: C: C2 neuralgia may occur from
manipulation, thermal injury, or stretch injury during
placement of C1 lateral mass screws. In such cases, C2 can
be sacrificed, without any relevant neurological sequela.
Only rarely, C2 can be injured during the exposure of C1-C2
facet capsule.
(116) Which of the following sentences is true regarding
lumbar spondylodiscitis?
A. The leading cause in most of the cases is Sta-
phylococcus Epidermidis
B. The typical postoperative course of spondy-
lodiscitis is the return of low back pain approx-
imately six weeks postoperatively
C. CRP has a high specificity and a low sensitivity
D. FDG-PET has the highest sensitivity and speci-
ficity among radiological exams
E. All of the above
Preferred response: B: The typical postoperative course of
discitis consists of initial resolution of symptoms, with
subsequent return of low back pain approximately six weeks
post-operatively. The most common cause of spondy-
lodiscitis is Staphylococcus Aureus (60%). High values of
CRP are extremely sensitive. MRI has the highest specificity
and sensitivity [34].
(117) 34-year-old patient underwent a postero-lateral
approach for T8-T9 thoracic disc herniation. He
recovered well after surgery, and he showed no
complications. Two months after the procedure, he
developed a burning and constant back pain. Neuro-
logic examination demonstrated a slight strength
reduction in the lower limbs and reduction of range of
motion of the trunk. Thoracic CT scan was negative
for any complication. What do you suspect?
A. Adamkiewicz artery ischemia
B. Post-operative back pain
C. Iatrogenic arachnoiditis
D. Focal iatrogenic instability
E. None of the above
Preferred Response: C: Spinal arachnoiditis is a non-
specificinflammatory process of the arachnoid layer of the
spinal cord or cauda equina. Iatrogenic arachnoiditis may
occur after spine surgery that is considered as an indepen-
dent risk factor. It has been reported that nucleus pulposus of
the intervertebral disc may cause focal arachnoiditis.
Clinically it appears as burning pain, constant in nature, and
worsened by activity with a latency of 1–6 months after the
procedure. Neurologically, it can be associated with slight
strength reduction, Positive straight -leg raise sign, tender
sciatic notch, limited range of motion of the trunk, and
paravertebral muscle spasms. CT scan can be normal or
show calcification or ossification of the spinal arachnoid,
called arachnoiditis ossificans [68].
(118) What is the MRI appearance of spinal arachnoiditis?
A. Conglomerations of nerve roots located centrally
within the thecal sac.
B. Nerve roots are clumped and attached peripher-
ally to the meninges
C. Increased soft tissue signal within the thecal sac
with central obliteration of the subarachnoid
space
D. A + B
E. A + B + C
Preferred Response: E: MRI appearance of spinal arach-
noiditis follows three patterns. The first is a conglomerations
of nerve roots located centrally within the thecal sac. The
second is characterized by nerve roots that are clumped and
attached laterally to the meninges. The third pattern
demonstrates increased soft tissue signal inside the dural sac
with central obliteration of the subarachnoid space [69].
(119) Which of the following are major risks for perioper-
ative blindness due to ischemic optic neuropathy?
A. Anemia, dehydration, and hypotension
B. Hypothermia, hyperoxygenation, hypotension
C. Hypoxia, anemia, blood dilution
D. Preoperative cataract, hypotension
E. None of the above
Preferred Response: A: One of the most common mecha-
nisms leading to perioperative blindness is ischemic optic
neuropathy. Indeed, the prolonged prone position may result
in central retinal artery occlusion by direct compression.
Risk factors for ischemic optic neuropathy include anemia,
dehydration, and hypotension.
(120) Which of the following is a risk facto r for acute res-
piratory distress syndrome (ARDS) in patient under-
going spine surgery?
A. Pulmonary contusion
B. Spinal cord injury
C. Instrumented surgery
D. A + B
E. A + B + C
226 A. Bocchetti et al.
Preferred Response: D: Severe and diffuse lung injury, like
acute respiratory distress syndrome, may complicate the
post-operative management of patients undergoing spine
surgery. Major risk factors are aspiration, pulmonary con-
tusion, hypotension, multiple transfusions, infection, spinal
cord injury and sepsis [40].
(121) Which of the following lumbar disc herniation con-
figuration has the highest risk of recurrence?
A. Fragment-fissure herniations
B. Fragment-defect herniations
C. Fragment contained discs
D. Annular prolapse
E. C + D
Preferred Response: D: Lumbar disc herniation have been
divided by Carragee et al. in 2003 in four shaped-based
groups: fragment-fissure herniations, fragment-defect herni-
ations (large disc fragment with massive posterior annular
tear), fragment contained discs (incomplete annular tear),
and annular prolapse. Among these, the fragment-fissure
herniations were associated with the best outcomes, whilst
annular prolapses carry a 38% recurrence rate [70].
(122) Which of the following is a risk factor for
post-operative C5 palsy?
A. Female gender
B. Calcified yellow ligament
C. Ossified posterior longitudinal ligament
D. C5-C6 foraminal stenosis
E. All of the above
Preferred Response: C: Risk factors for postoperative C5
palsy include ossification of the posterior longitudinal liga-
ment (OPLL), narrow intervertebral foramen at level of the
surgery, C4-C5 foraminal stenosis independently from the
level of the surgery and male gender [71].
(123) A 56-year-old patient was carried to the emergency
room because he developed progressive drowsiness.
The CT scan showed a diffuse cerebellar hematoma
(Fig. 10.9). He underwent L3-L4 PLIF at another
institution two weeks prior. The surgical report did
not mention any complicat ions during surgery. What
could be the cause of the hematoma?
A. It cannot be stated. There is no association with
the previous spine surgery.
B. Thromboembolic cerebellar stroke and subse-
quent infarction
C. Delayed CSF leak
D. Hyper inflammatory immune response
E. None of the above
Preferred Response: C: Occult dural tears are rare but
described occurrence in spine surgery. They can lead to
delayed symptomatic CSF leak. It can appear after few days
or weeks after surgery. One of the potential complications of
CSF leak is cerebellar hemorrhages and brain sagging [72].
(124) What are the most common risk factors for remote
cerebellar hemorrhage due to dural tear and CSF leak?
A. Hypertension
B. Coagulation disorder
C. Postoperative subfascial drains
D. B + C
E. A + B + C
Preferred Response: E: Several retrospective analysis and
reviews studies pointed hypertension, coagulation disorders
and the placement of subfascial drains as the most common
risk factors for remote cerebellar hemorrhage due to iatro-
genic spinal CSF leak [72].
(125) Which of the following statements is false regarding
perineural scar formation?
A. Neither scar nor the use of scar-inhibiting tools
impact clinical outcomes
B. Systemic and epidural corticosteroids neither
reduce the risk of scar formation nor improve
short- and long-term outcomes
C. Epidural fat should be left as intact as possible
D. Gelatin sponges increase scar formation
E. A + B
Fig. 10.9 Axial CT scan demonstrating cerebellar hematoma
10 Complications of Surgery of the Spine 227
Preferred Response: B: Epidural steroids are commonly
employed and have been shown to reduce the epidural scar
formation. They have also an inhibitory effect on
pain-transmitting C-fibers, which are the most prone to the
inflammation caused by disc herniation. Therefore, a combi-
nation of systemic and epidural corticosteroids leads to faster
symptoms relief and reduce the risk of scar formation [73].
(126) Which of the following sentences is true regarding the
correlation between nasal carrying of Staphylococcus
Aureus and surgical site infection?
A. There is a clear association between nasal car-
riage of S. aureus and occurrence of surgical site
infections.
B. Short-term mupirocin nasal ointment should be
administrated to patients before every elective
surgery
C. In patients carrying S. Aur eus, 21 days admin-
istration of mupirocin nasal ointment proved to
reduce surgical site infection
D. A + C
E. A + B
Preferred Response: A: Several trials reported a correlation
between the presence of S. Aureus in the nasal cavity and an
higher risk of surgical site infections. Short-term treatment
with mupirocin ointment (5 days) eliminates S. aureus in
most of these carriers. It has been suggested to test patients
for nasal S.Aureus before elective surgery, and only treat
those patients who tested positive with a short course of
mupirocin ointment [34].
(127) Which of the following is not a complication related
to the employment of orthosis?
A. Superior mesenteric artery syndrome
B. Psychological dependence
C. Recurrent laryngeal nerve palsy
D. Pulmonary edema
E. Dysphagia
Preferred Response: C: Among the reported complication
related to the employment of orthosis, recurrent laryngeal
nerve palsy has never been described. The superior mesenteric
artery syndrome or cast syndrome is due to the artery stretched
across the ventral aspect of the distal duodenum. It determines
postprandial bilious emesis, epigastric pain, and distention
from partial duodenal obstruction. Psychological dependence
and secondary gain may occur after chronic orthosis use that
determines a change in body perception. Pulmonary edema
may be due to increased venous return. Dysphagia is reported
in up to 2% of cases and is caused by impaired larynx
movement required for coordinated swallowing.
(128) During a C3 corpectomy when drilling laterally to the
unco-vertebral joint a sudden, non-pulsatile, copious
dark bleeding occurs. What do you suspect?
A. Internal jugular vein injury
B. Vertebral artery injury
C. External jugular vein injury
D. Epidural bleeding due to decompression
E. None of the above
Preferred Response: B: Vertebral artery injury is usually
featured by sudden, non-pulsatile, copious bright red
bleeding. Nevertheless, it may be dark because of injury to
the surrounding venous plexus. This occurrence may be
catastrophic, because the hemorrhage may be massive and
cause cerebral ischemia/embolic events.
(129) How would you manage vertebral artery injury
occurred during an anterior cervical approach?
A. Tamponade
B. Repair
C. Ligation
D. Coagulation
E. A + B + C
Preferred Response: E: Strategies to manage a vertebral
artery injury during an anterior cervical approach include
repair tamponade, and ligation. Hemostats, such as Gelfoam
and oxidized cellulose, may be useful. If they failed, the
exposure should be enlarged, the artery exposed, and the
surgeon must then weigh the options of vertebral ligation
versus repair [74].
(130) Which of the following can be considered a specific
cause of spinal cord injury during laminoplasty?
A. Stepwise opening of the laminae involved
B. Injury of the dura mater or spinal cord during
drilling
C. A + B
D. Positioning
E. Post-operative kyphosis
Preferred Response: C: The most comm on causes of spinal
cord injury strictly related to laminoplasty procedure are
stepwise opening of the laminae. It means drilling and
opening laminae one by one. This can cause kinking of the
spinal cord at the edge of the residual lamina, causing injury.
Thus, laminae should be opened en bloc. Moreover, exten-
sive use of the drilling obliquely oriented increase the risk of
dura mater and spinal cord injury [75 ].
(131) A 53-year-old man complained of axial neck pain
(5/10), walking impairment and difficulties with fine
228 A. Bocchetti et al.
motor skills. Neurological examination showed
increased deep tendon reflex (+3) in the lower limbs,
positive Babinski and Hoffman signs, and increased
extensor muscles tone. MRI showed a straightened
cervical spine and a C3-C6 cervical spondylotic
myelopathy. You decided to perform a C3-C6
laminoplasty. After the surgery, the patient has a
slight improvement in walking and fine motor skills.
Nevertheless, neck pain worsened (NRS 7/10). What
is the cause of such occurrence?
A. Laminoplasty is discouraged in cases of neck
pain
B. WFNS guidelines for cervical spondylotic
myelopathy discourage laminoplasty in straight-
ened cervical spine
C. It is normal pain due to muscle healing
D. Laminoplasty should not be performed for more
than two levels
E. A + B
Preferred Response: A: WFNS guidelines for cervical
spondylotic myelopathy state that laminoplasty should be
avoided in patients with cervical kyphosis and significant
preoperative axial neck pain. This is because neck pain itself
is a common complication of laminoplasty. Laminoplasty
can be employed in neutral or lordotic cervical spine [12, 76].
(132) Which of the following are specific complication of
sacroiliac joint fusion?
A. Sacral vessels injury
B. Genitofemoral nerve compression
C. Sacral fracture
D. Lumbar adjacent segment disease
E. A + B + C
Preferred Response: D: Sacroiliac joint fusion has become
increasingly employed lately as a treatment for sacroiliac
joint pain and for joint pathology. Among the specific
complication of this technique there are: failure in pain
relief, failure in fusion and lumbar adjacent segment disease,
whose rate can be as high as 16%. This is due to the addi-
tional pressure applied to the lowest lumbar disc and facet
joints, that become overloaded, injured, and a source of pain
[77].
(133) Which of the following sentences is true about com-
plications of vertebral artery injury?
A. A postoperative angiogram should be performed
in order to rule out significant injury, stenosis,
pseudoaneurysm, or arteriovenous fistula.
B. In cases of serious complication, vessels sacrifice
should be considered.
C. Vascular complications may occur from days to
years after surgery
D. A + B
E. A + B + C
Preferred Response: E: Even if the proper post-operative
management of vertebral artery injury remains controversial,
most authors suggest performing a postoperative angiogram
in order to rule out significant complications. Detecting a
complication may lead to either introduce anticoagulant or
antiplatelet therapy or vessel sacrific. Late complications of
vertebral artery injury may occur from days to years after
surgery and may consist of arteriovenous malformation,
thrombosis with embolic incidents, cerebral ischemia,
stroke, and even death.
(134) Which of the following statements is false regarding
ureteral injury during anterior approaches to the
lumbar spine?
A. Ureter reconstruction should be always done
over a stent that can be subsequently retrieved by
cystoscopy.
B. During reoperations, or in cases of retroperi-
toneal fibrosis, tumor, or previous irradiation,
dissection should proceed with the aid of sponges
or Kittners.
C. The first repair attempt should always be a direct
end to end anastomoses, independently from the
injury type
D. In cases of post-operative hydronephrosis CT
scan with contrast injection and delayed scans
should be performed
E. All of the above
Preferred Response
: C: The type of injury always leads to
the repair strategy. In fact, net lacerations require simple end
to end anastomosis, whereas segmental injuries may warrant
segmental resection and re-anastomosis or complicated
reconstructive techniques such as appendiceal interposition
or uretero-ureteral anastomosis [78].
(135) What is the correct definition of cage subsidence in
ACDF?
A. 3 mm loss of height comparing the immedi-
ate postoperative intervertebral height with the
intervertebral height at the last follow-up moment
B. Failed fusion after disc placement leading to
formation of aberrant anterior bridges of bone
C. Less than 3 mm of translational motion and less
than 5° of angular motion on flexion and exten-
sion radiographs 6 months after surgery
10 Complications of Surgery of the Spine 229